Pay for performance

Correctional care

ACP news

In response to the CMS' recently proposed changes to increase the work relative value units (RVUs) assigned to many E/M services, ACP this week released a new interactive revenue calculator. The online calculator enables College members to estimate their revenue from providing E/M services to Medicare patients if the recommended changes take effect as proposed in 2007.

The recommendations represent the most comprehensive changes ever proposed to E/M services and would substantially increase payments associated with the most frequently billed physician services. For example, the work component for RVUs would increase 37% for an intermediate office visit (99213), 29% for a moderately complex office visit (99214) and 31% for a moderately complex hospital visit (99232). In addition to this update to work RVUs, the proposed rule also describes changes to the way practice expenses are calculated.

ACP estimates that overall Medicare payments to internists would increase on average between $4,000 and $9,000 per year, but this new calculator tool allows physicians to see a potential increase based on their own practice patterns. To generate an estimate, physicians input their weekly E/M totals for Medicare patients and the number of weeks worked per year. Note that low-level codes will show a decline due to the requirements of budget neutrality, but physicians should see their aggregate E/M revenue increase once they enter the number of weekly visits for intermediate and higher level services.

This tool estimates increases from Medicare only. However, E/M service payments by private health plans that use the Medicare-approved RVUs for determining their own fee schedules are likely to increase as well.

Clinical news in the headlines

The following articles appear in the July 4 issue of Annals of Internal Medicine. Full text is available to College members and subscribers online.

Both acupuncture and sham acupuncture improve knee pain. In a study of more than 1,000 patients with osteoarthritis knee pain, both acupuncture and sham acupuncture improved knee pain compared with standard treatment of doctor visits and anti-inflammatory drugs.

About 53% of the acupuncture group reported less pain and better function at 26 weeks, compared with 51% of the sham acupuncture group and 29.1% of the no- acupuncture group. All participants could receive six physical therapy treatments and could take anti-inflammatory medications as needed. Authors say the study supports using acupuncture in multimodal treatment of patients with knee osteoarthritis, even if the mechanisms of its effects remain unclear.

Mediterranean diets improve heart risk factors better than low-fat diet. Older adults with risk factors for heart disease who ate one of two Mediterranean-type diets for three months had improved blood pressure, cholesterol levels and blood sugar levels compared with a group that ate a low-fat diet. The 772 adults had diabetes or three or more other risk factors for heart disease, such as smoking, abnormal cholesterol levels or high blood pressure.

Both Mediterranean diets consisted of large amounts of whole grains, fruits and vegetables. One group increased consumption of vegetable fats and received free virgin olive oil. The second Mediterranean group increased consumption of vegetable fats and oils and received free walnuts, hazelnuts and almonds. The third group decreased consumption of all fats.

In addition to improved blood pressure, cholesterol and blood sugar levels, both Mediterranean diet groups found it easier to maintain the diets than those in the low- fat diet group. Study authors say that this may be because the Mediterranean diets were closer to the Spanish participants' actual diets.

This short-term study measured changes in risk factors for heart disease but did not look at the effects of any diet on actual heart attacks and strokes.

In the study, a total of 503 patients with resectable gastric cancer were assigned to either a three-week course of perioperative chemotherapy (epirubicin, cisplatin and fluorouracil) followed by surgery, or surgery alone. While the number of deaths within a month of surgery was similar for both groups, patients who received the perioperative regimen had smaller and less-advanced tumors than those in the surgery-alone group, and their five-year survival rate was 36% compared with 23% in the surgery-only group. The study is published in the July 6 New England Journal of Medicine.

Perioperative chemotherapy may be the best way to improve survival for gastric cancer patients, but only if they are referred early to an oncologist, said an accompanying editorial. It is not unusual, however, for these patients to be referred only after they have undergone gastrectomy, making them ineligible for the perioperative regimen.

The new findings suggest that the time to consider chemotherapy is before surgery, the editorial continued. Surgery—the standard of care for this type of cancer—is up to 90% effective when the cancer is localized to the stomach, said the editorial—but less than 30% of cases are cured by gastrectomy if the tumor has extended through the gastric wall. Adjuvant chemotherapy, while effective for other cancers, has not significantly improved survival for those with stomach cancer.

According to the July 6 Wall Street Journal, stomach cancer remains one of the most deadly cancers because it is often discovered late, especially in patients living outside of Western countries. The disease kills about 700,000 people worldwide each year.

FDA update

The FDA recently approved a new treatment for age-related macular degeneration as well as the first generic version of a widely prescribed antidepressant.

Ranibizumab injection, marketed as Lucentis by Genentech, was approved to treat neovascular or wet age-related macular degeneration (AMD). Monthly doses of the drug have been shown to maintain vision in more than 90% of patients with this type of AMD, said a June 30 FDA news release.

About 155,000 people in the U.S. are diagnosed each year with wet AMD and it is a common cause of vision loss in people over age 55, the FDA release said. Ranibizumab injection works by blocking the growth of abnormal leaky blood vessels, preventing progression of the disease.

In clinical trials, nearly 95% of patients treated with the new drug maintained their vision at 12 months, compared with 60% in a control group, said the release. The most common side effects were conjunctival hemorrhage, eye pain, floaters, increased eye pressure and inflammation of the eye.

The FDA also approved the sale of sertraline, the first generic version of Zoloft, used to treat major depressive disorder. The drug will be available as tablets and as a liquid concentrate (sertraline hydrochloride), said a June 30 FDA news release. Zoloft was the sixth highest selling brand name drug in the U.S. last year, with sales over $2.5 billion.

The FDA last week sent a warning letter to the maker of Fluzone regarding problems at the Pennsylvania plant where the monovalent concentrate used in making influenza vaccine is manufactured.

Violations noted in the letter concern sterility problems in monovalent concentrates produced at Sanofi Pasteur's Swiftwater, Penn., plant, according to the FDA's Web site. A small percentage of the monovalents were lost, said the FDA, but the loss should not significantly affect the availability of Fluzone in the upcoming flu season.

The FDA started conducting annual inspections of flu vaccine production facilities after a Chiron plant was closed in 2004, which caused a severe shortage of vaccine. The agency first advised Sanofi Pasteur about sterility violations during an inspection of the Swiftwater facility in March 2005. A warning letter was issued after the company failed to address problems found during that inspection, said the FDA.

The company has 15 days from the date of the letter to submit a plan for correcting the violations or face enforcement action.

The FDA's letter to Sanofi Pasteur as well as an FDA Q&A section about the warning are online.

Also see the Centers for Disease Control and Prevention's Q&A on U.S. production, supply and distribution of flu vaccine.

The FDA posted a safety alert on its Web site about incidents of intracranial hemorrhages among HIV patients treated with tipranavir.

Boehringer Ingelheim advised federal regulators that 14 people taking tipranavir (Aptivus) suffered intracranial hemorrhage and eight of those patients died, said a June 30 alert posted on the FDA's MedWatch Web site. The reports prompted an addition to the drug's black box warning, which already warns of liver failure.

The affected patients were among 6,840 HIV-1 infected patients who received tipranavir capsules along with ritonavir in clinical trials testing combination antiretroviral therapy.

The FDA noted that many of the patients who experienced hemorrhages had other medical problems, such as lesions, head trauma or recent neurosurgery that may have contributed to the hemorrhages. The agency said it is continuing its investigations.

Pay for performance

Three large health plans have agreed to incorporate into their pay-for-performance programs physician data collected by the ABIM for recertification.

The plans—UnitedHealthcare, Aetna and Horizon Blue Cross Blue Shield of New Jersey—will use ABIM's maintenance of certification program data to qualify physicians for recognition or rewards, said a June 28 ABIM news release. More than 100,000 internists and subspecialists nationwide will be eligible to participate, provided that they are enrolled in ABIM's maintenance of certification program.

After completing a Web-based practice improvement module, participating physicians can choose to have their scores sent to any participating health plan to be used in quality recognition programs, said the release. The voluntary program allows physicians to take advantage of incentive programs, said the release, without adding to their administrative burden.

In addition to these recently announced plans, Blue Cross and Blue Shield of Nebraska began working with ABIM in March 2006.

Correctional care

The National Conference on Correctional Health Care will hold its annual meeting this year in Atlanta Oct. 28- Nov. 1. Physicians and other clinicians, as well as attorneys and administrators, are invited to attend.

The preeminent forum for correctional health care, the conference will include more than 100 educational programs in nine different tracks, including clinical care, mental health, health care delivery, and research and development.

Two preconference seminars will also delve into critical issues in correctional health care, including managing infectious diseases and risk management. ACP is represented on the commission's board of directors.

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Copyright 2006 by the American College of Physicians.

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A 66-year-old man is evaluated for a persistent rash for 6 years' duration. The rash waxes and wanes in severity, and it becomes pruritic only after he becomes hot and sweating, such as when he mows the lawn or exercises. It has always been limited to his back and lower chest. He has never treated it. The patient is otherwise well, has no other medical problems, and takes no medication. Following a physical exam, what is the most likely diagnosis?

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